Here we go again, back to those Ingenix algorithms and business models, getting a rerun of sorts of what occurred in 2011. In 2011 there was one main lawsuit from the AMA along with many others that were filed (some being still settled) over using formulas that short changed doctors and patients on out of network chargees. In addition, all other insurers who licensed and used the formulas were also drug into court for settlements. This was a big deal and now we have another lawsuit with again, other insurers being named for using the formulas of Ingenix once again. Here’s a case that has not settled yet as an example and one that just recently settled.

Here’s a back link to the big settlement by the AMA. Again this is only one of many and at the time I was writing a series of blog posts called “The Attack of the Killer Algorithms and this was chapter 19.

If you missed this along the way, things go so ugly with the Ingenix name, United Healthcare changed it to Optum, which you see all over the place today, as they are buying up broke doctor practices and urgent care centers like they are going out of style. There’s 2 sides to United Healthcare, one that does insurance and the other Optum side that’s buying up and creating software was well as consuming and acquiring companies that have anything to do with doctors.

So again with this new lawsuit, which was created from the efforts of a high ranking former United Healthcare executive, not just an employee, we are seeing the same process again, Ingenix algorithms and models followed to fiddle with risk scores, make patients look sicker and get more money from the government this time instead of doctors.

Express Scripts ended up at one point in time a while back buying the old United Healthcare pharmacy benefit business and acquired some software and algorithms in the process and in 2010 was bragging how they are going to predict if you will take your medications. This flawed scoring still goes on today.

The entire lawsuit can be read here and there’s quite a few pages to the pdf to read. Benjamin Poehling was the former high ranking executive that filed the whistle blower lawsuit. It’s kind of uncanny that Poehling came from Arthur Andersen, where the current CEO of United Healthcare worked as Anderson’s CFO and all the Enron issues were on his watch. Enron lead to the end of the Arthur Andersen auditing firm due to fraud. Here’s a few quotes from the suit…

“United’s senior management push relentlessly to increase United’s revenue from risk adjustment. Tellingly, UHMR has assigned risk adjustment to its Finance Department, not one of its clinical departments. (Relator was assigned to his job despite having no clinical background.) In 2010 and 2011, UHMR has implemented projects referred to as “remediation plans”, “focus area projects,” or “affordability agendas” to increase IOI.

UHG engages in an aggressive and extensive effort to find a justification or pretext to submit risk adjustment claims for additional diagnoses—regardless of whether the patient had or was actually treated for the diagnosis in the relevant period by a qualifying provider. United’s program has some components that are broad-based, and others that target specific high value HCCs. As an overall goal, UHG attempts to reach each of its members at least once every two years through one of its programs designed to find additional risk adjustment claims.

Ingenix conducts chart reviews on behalf of UHMR, UHCS, and commercial clients. In the retrospective chart review process, Ingenix identifies provider charts to review and arranges for the charts to be collected. It uses both internal coders and also contracts with external vendors to review and code the charts. 129. These vendors review charts using a blind review. In a blind review, the reviewer codes every condition he or she identifies from the chart without knowing what codes the provider identified from the chart previously. Thus, the reviewer works from the raw chart material and reaches independent conclusions.

Under the COI program, United pays providers approximately $100 for each diabetes patient they assess for diabetes complications, submit a supporting diagnosis via a claim, and submit a medical record with matching documentation. In addition, it pays $200 for each doctor that receives training on the COI program and diagnosis coding. Recently, the COI program has expanded to other conditions that United suspects are frequently undercoded, such as chronic kidney disease (“CKD”), and chronic pulmonary disease (“COPD”).

Relator knows that at least the following United executives know about some or all of the problems discussed herein, and have participated in the scheme to continue submitting fraudulent claims and to refuse to correct previously submitted false claims: Stephen Hemsley, UHG Chief Executive Officer; Gail Boudreaux, UHG Executive Vice President and CEO of United Healthcare; Larry Renfro, Optum CEO; Tom Paul, UHMR Chief Executive Officer; Cindy Polich, UHMR President; Lee Valenta, Ingenix’s former Chief Operating Officer (and current President of Ingenix’s Life Sciences Division); Jack Larsen, former CFO of PSMG (and current CEO of UHCS); Scott Theisen, UHMR Senior Vice President of Finance; Jeff Dumcum, Senior Vice President of Ingenix; and David Orbuch, PSMG Chief Compliance Officer.

And this….

“United’s refusal to correct errors in its risk adjustment claims is so extreme that it submits risk adjustment claims to CMS for diagnoses taken from claims that it itself refuses to pay as being fraudulent and/or abusive.

United developed “playbooks” containing ideas for increasing its risk scores. These playbooks are garnering top-level attention at the company while the myriad problems with United’s risk adjustment programs and processes go unresolved. 195. United conceals the one-way nature of its risk adjustment programs from CMS and even its investors. For example, United’s remediation plan for 2010 that sought to increase IOI by $800 million allocated $100 million to “Project 7.” Project 7 was United’s codeword for initiatives to increase risk adjustment payments. The company used a codeword (as opposed to “growth,” “enrollment,” or “claims”) because it did not want CMS or other investigatory government agencies to know it had a campaign to claim an additional $100 million through risk score increases.

United customizes its kickbacks depending on the nature of its overall reimbursement arrangement with the provider group. The providers United chooses to pay additional amounts for increased risk scores are those that do not already have an incentive to upcode diagnoses. United uses three basic payment structures for its providers: (1) percent of premium capitated providers, which receive a percent of United’s CMS premiums for its patients; (2) “fixed” capitated providers, which receive PMPM payments from United that are not tied to United’s CMS premiums; and (3) feefor-service providers, which are paid based on the claims they submit to United.”

If you made it through those paragraphs you can easily see how complex insurers have made medical billing for sure. Once again we come back to the business models of Ingenix and some of the automation in the IRAD data base to work these claims. Here’s another billing subsidiary United bought, again we’re talking coding and billing here.

I talk too about the United/Optum incest at times too with HHS and CMS and here’s a blast from a few years ago…this was the beginning of pushing “population health” that all know the term and nobody really knows what it does half the time to even include vendors of the algorithmic processes. This is where the government bought yet another United Healthcare model.

Former Acting director of CMS, Andy Slavitt claims Simon is a good friend of his and let’s not forget that Andy Slavitt was the CEO of Ingenix when a lot of this was going on. Larry Renfro came in later from his executive position at AARP to run the Ingenix show.

United Healthcare sure seems to be lining up some big executives as well with last year hiring the former CEO of Stanford University Healthcare to work for United as a VP and recently in the UK, Optum hired Nick Seddon, who worked for David Cameron as his special healthcare adviser. There’s a group in the UK that is also bringing attention to the fact that one company, United/Optum has been taking over way too much ground and is not leaving enough competition out there with other countries.

The entire suit takes a while to read but there’s a ton of detailed explanations as to what United and other insurers taking advantage of their consulting and billing services are accused of. Again, do leopards change their spots? Here’s another suit you might want to read about…it just does not stop when you have complex built algorithms that can spin around faster than you can take a deep breath to score and stick you with more risks than you ever dreamed of, all for the sake of making money from the government.

Feel free to search this blog, there’s plenty of information like this written since 2008 on how companies cheat with computer code and algorithms…BD

United Healthcare, the largest provider of Medicare Advantage (MA plans) services, is being sued by the Department of Justice (DOJ) for fraud. To give you a sense of United Healthcare’s size consider that just their third quarter revenue was $46.3 billion, up 11.6 per cent from the same period a year earlier, and the bulk of the growth was billing services and data analysis for healthcare groups, which ws up 34 percent since the beginning of 2016.

Medical charts, the primary source of diagnostic data were reviewed looking for incremental increases but not for errors that would decrease the risk adjustment. New diagnostic codes were submitted, but an erroneous diagnosis was not deleted. On a two-way street, “they do not look both ways.” And these reviews were profitable, a $30 cost for chart review resulted in an average of $450 in additional payments. Ingenix sought to find additional diagnosis by using data analytics to identify practices, where chronic conditions were underreported based on population prevalences or where a new diagnosis was suggested by medications patients were receiving. Here the physician was contacted with patient assessment forms (PAFs) to consider these diagnoses for the patient. Physicians receive a small fee for reviewing these PAFs. Ingenix also developed initiatives designed to get patients to visit their doctors each year. But wait a minute, these programs encourage physicians to screen patient’s more carefully and to encourage annual checkups.

Dark Arts of Mathemical Deception

Professor Charlie Siefe of NYU, a mathematician debunks clinical trials, and few other items to where data is spun and fools you, every day example, hear about the perfect butt algorithm and more. These are probably some things you have never thought about but again after listening to what he has to say, it’s time to think about being skeptical. Here’s a radio show that also talks about the same topics.

This video digs in a bit further with how fictitious business models are used by banks and companies do this too. The models are so complex that CEOs don’t even understand them. “Quants, The Alchemists of Wall Street will take you through how “math models” work at banks and financial institutions in a way that even the layman can understand. More videos like over at theAlgo Duping/Killer Algorithm Page. Bank of America will also tell you“IT’ is a business” how they make money.

Weapons of Math Destruction

This is a lecture where Kathy O’Neill, a former Quant who worked for a Hedge Fund (Weapons of Math Destruction) on Wall Street will tell you what is done with your retirement money and more. The banks and companies use technology to take advantage because they can. “Of course we are going to take advantage because our tools are our brains…if they could figure out a way to take advantage of pension funds they would, a good interview with explaining smart money and dumb money.

Algorithms Shape The World

This is a very good presentation done a TED Conference and really was the one that got everyone started thinking about algorithms and today it’s talked about a lot. As he says “if you’re an algorithm, life is looking pretty good, but can’t say the same for humans”. What is a black box? Nobody has any control over the flash crash. We have moved forward a bit but still we are writing the unreadable and lost the sense of some of what is happening. Nice plug for Nanex here with research.